NPIMap

Organization Active NPI

Wayne County Hospital

Doing business as Humeston Family Medical Clinic

  • Rural Health Clinic/Center
  • Humeston, IA
National Provider Identifier
1275825838
Registry record updated Dec 6, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
WAYNE COUNTY HOSPITAL
Doing business as
Humeston Family Medical Clinic
Practice address
109 Broad St
Humeston, IA 50123-7736
Phone
(641) 877-6108
Fax
(641) 877-6123
NPI assigned
May 13, 2011
Last updated
Dec 6, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 6, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Daren L Relph
Title
Ceo
Phone
(641) 872-2260

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X

Addresses

Primary practice location

109 Broad St
Humeston, IA 50123-7736

Mailing address

PO Box 305
Corydon, IA 50060-0305
Phone (641) 872-5341

Other names 1

  • Humeston Family Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040212000233 IA Part B Supplier - Clinic/Group Practice 4082508734 Receives reassigned benefits from 59 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Corydon, IA; Humeston, IA; Seymour, ID
O20120328000101 IA Part A Provider - Rural Health Clinic 4082508734 Practice locations: Humeston, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1275825838. Details of each certification follow.

Rural health clinic certification: CCN 168548

Legal name
WAYNE COUNTY HOSPITAL
Doing business as
HUMESTON FAMILY MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 28, 2012
Last certification
Jun 19, 2018
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
109 Broad St
Humeston, IA 50123-7736
Related CCNs
161358

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
16D2025845Wayne County Hospital109 Broad Street, Humeston, IA 50123Provider-performed microscopyJun 16, 2027

National Provider Directory

National Provider Directory
Tax ID family
Wayne County Hospital8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Devin Rodgers Individual Corporate OfficerTrustee Jan 16, 2023
Denise a Hook Individual Corporate OfficerChief Financial Officer Aug 27, 2010
Operational/Managerial ControlCfo Jan 1, 2011
Rhonda Ewing Individual Corporate Director Jan 1, 2015
Darrell Cook Individual Corporate DirectorBoard Member Jan 1, 2010
Daren L Relph Individual Corporate OfficerChief Executive Officer Jun 1, 2010 100%
Operational/Managerial ControlCeo Jun 1, 2010 100%
Donna Donald Individual Corporate DirectorBoard Member Jan 1, 2008
Wayne County Hospital Organization, Corydon, IA 5% Or Greater Direct Ownership Interest Jul 1, 2011 100%
Cynthia Shelley Individual Corporate DirectorTrustee Jan 1, 2021
Dewayne Watters Individual Corporate OfficerTrustee Jun 1, 2021
Jill Tueth Individual Corporate DirectorBoard Member Jan 1, 2010

Owners & managing parties with NPI records 7

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Lineville Medical ClinicLineville, IA, CCN 163435 Rural health clinic 5% Or Greater Direct Ownership Interest Jan 13, 2010
Seymour Medical ClinicSeymour, IA, CCN 168541 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Nov 1, 2010
South Central Iowa Medical ClinicCorydon, IA, CCN 168547 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2011

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 3

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1305244800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1354752000000",
    "number": "1275825838",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 305",
            "city": "CORYDON",
            "state": "IA",
            "postal_code": "500600305",
            "telephone_number": "641-872-5341",
            "fax_number": "641-872-3116"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "109 BROAD ST",
            "city": "HUMESTON",
            "state": "IA",
            "postal_code": "501237736",
            "telephone_number": "641-877-6108",
            "fax_number": "641-877-6123"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAYNE COUNTY HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-05-13",
        "last_updated": "2012-12-06",
        "status": "A",
        "authorized_official_last_name": "RELPH",
        "authorized_official_first_name": "DAREN",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "641-872-2260"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Humeston Family Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Humeston, IA

Sources for this page

Verify at the official NPI Registry.